Moderate-to-severe Mitral Regurgitation Research Articles

1110 PROGNOSTIC IMPACT OF SIGNIFICANT MITRAL REGURGITATION IN PATIENTS WITH SEVERE LOW FLOW, LOW GRADIENT AORTIC STENOSIS UNDERGOING TRANSCATHETER AORTIC VALVE REPLACEMENT

Abstract Aim This study sought to determinate the prevalence, clinical impact, and clinical outcome of significant moderate-to-severe mitral regurgitation (MR) in patients with severe low flow, low gradient aortic stenosis (LFLG-AS) undergoing transcatheter aortic valve replacement (TAVR). Methods All consecutive patients with severe LFLG-AS undergoing TAVI in two high-volume Italian centres from 2013 to 2022 were prospectively included. LFLG-AS was defined as indexed aortic valve area (iAVA) ≤0.6 cm2/m2, mean transaortic gradient <40 mmHg and stroke volume index <36 ml/m2. LFLG-AS was classified as classical if left ventricular ejection fraction (LVEF) was <50%, and paradoxical in patients with preserved LVEF >50%. Demographic, clinical, instrumental, and procedural features were systematically collected by using an electronic case report form. MR severity was graded according to the current guidelines, and patients were categorized based on the MR severity at baseline in two groups: mild and moderate-to-severe MR. The primary study outcome was the composite of all-cause mortality and rehospitalization for worsening heart failure (HF) up to 1 year; secondary outcomes were the single components of the primary outcome. Results The study included 268 patients [81±6 years; 142 (53%) females]; moderate-to-severe MR was reported in 57 patients (21%). At baseline moderate-to-severe MR compared to those with mild MR showed statistically significant differences between age (p 0.008), female sex (p 0.007), hypertension (p 0.036), diabetes (p 0.001) atrial fibrillation/flutter (p 0.018) and chronic kidney disease (p 0.012). In the overall population, only one patient died during the hospitalization and at one-year follow-up, the primary outcome was reported in 49 patients (18%); all-cause death occurred in 26 (10%), and HF rehospitalization in 24 (9%). Regarding the two subgroups, Kaplan-Meier curves showed that survival free from the composite outcome was significantly lower in patients with moderate-to-severe MR compared to those with mild MR (Log Rank <0.001, Figure 1A). Survival free from all-cause mortality and HF rehospitalization was also significantly lower in patients with moderate-to-severe MR (Log-Rank <0.001 and Log-Rank=0.002, respectively; Figure 1B and 1C). Conclusion In this study, many patients with LFLG-AS undergoing TAVR had coexisting moderate-to-severe MR. TAVI confirmed a high safety profile, LFLG-AS patients showed a high incidence of adverse events up to 1 year, especially those with coexisting moderate-to-severe MR. Moderate-to-severe MR should be duly considered for better prognostic stratification and clinical management of these particular TAVR patients during follow-up. Figure 1

E-33 | Transcatheter MitraClip Device Therapy in Patients with Cardiogenic Shock: A Meta-analysis of Single Arm Studies

Moderate-to-severe mitral regurgitation (MR) is present in up to 10% of patients with cardiogenic shock (CS). Patients with CS and concomitant MR have a guarded prognosis with conventional medical therapy alone. The purpose of this study was to explore outcomes of MitraClip device repair of severe MR in this high-risk patient population with shock.

Correlation of intraprocedural and follow up parameters for mitral regurgitation grading after percutaneous edge-to-edge repair

Abstract Background Percutaneous edge-to-edge mitral repair has merged as an effective therapy for moderate-to-severe mitral regurgitation (MR) in high surgical risk patients. Transesophageal echocardiogram (TEE) is crucial for procedure guiding and immediate result evaluation, whereas transthoracic echocardiogram (TTE) is largely used in follow up. However, there is no consensus on the best intraprocedural parameter to evaluate residual MR. Purpose To evaluate the predictive value of different MR parameters from intraprocedural TEE with grading in consecutive TTE during the follow up. Methods All the consecutive patients who underwent percutaneous mitral repair with the MitraClip system between 2010 and 2020 in our tertiary university hospital were considered for this study. Immediate posprocedural MR parameters (number of jets, summatory and maximum vena contracta (VC), summatory and maximum 3D effective regurgitation orifice (ERO) and pulmonary vein (PV) flow parameters) were reassessed when possible blindly to the follow up MR grading in sequential TTE. Results We included 88 patients (64.8% males) with a mean age of 76±10 years. Baseline MR was graded as moderate-to-severe in 13 (14.8%) and severe in 75 (85.2%). The most frequent MR etiology was secondary (44.3%) followed by primary (35.2%) and mixed (20.5%). Patients presented with mild left ventricular systolic dysfunction (LVEF 44.5±15.3%) and dilatation (LVEDVi 71.8 [51.5–102.8] mL/m2). MR grading distribution remained stable at 1 and 6 months follow up TTE. Among all the aforementioned criteria only summatory and maximum VC remained significant for different MR grade prediction. Thus, these values were able to identify MR ≥3 at 1 and 6 months (Table). Moreover, on ROC analysis maximum VC demonstrated an excellent discriminatory power to identify significant MR at 6 months (Figure). Thereby, a cut-off point of 0.45 cm was able to predict MR ≥3 with 88% sensitivity and 89% specificity. Conclusion Among intraprocedural TEE parameters to evaluate residual MR in percutaneous edge-to-edge mitral repair, maximum and summatory VC appeared to be the more reliable to predict significant insufficiency in the follow up. Funding Acknowledgement Type of funding sources: None. Table 1. Differences in intraprocedural TEE VC in relation with significant MR in follow-up TTEFigure 1. ROC curve of maximum VC for prediction of significant MR at 6 months

Impact of mitral valve anatomy suitability in echocardiographic and clinical evolution in patients referred for percutaneous edge-to-edge repair

Abstract Background Percutaneous edge-to-edge mitral repair has become an effective therapeutic alternative to surgery in high-risk patients with moderate-to-severe mitral regurgitation (MR). A traffic light system has been proposed to evaluate echocardiographic suitability for this therapy. However, few data is available regarding prognostic impact of these criteria. Purpose To study the impact of imaging eligibility classification in echocardiographic and clinical evolution. Methods We evaluated all the consecutive patients who underwent percutaneous mitral repair with the MitraClip system between 2010 and 2020 in our tertiary university hospital, excluding the redo procedures (n=1). Imaging eligibility classification was blindly made by two experts in structural heart disease. Pre and posprocedural echocardiographic measurements were reassessed and clinical events were collected from medical records. Results 87 patients (65.5% males) with a mean age of 76±10 years were finally included. Regarding mitral valve disease, 13 (14.9%) was graded as moderate-to-severe whereas 74 (85.1%) was considered severe. MR etiology was: functional 44.8%, organic 34.5% and mixed 20.7%. Prior to the procedure the NYHA class was III or higher in 88.5% and LVEF was 44.4±15.4%. Eligibility criteria was: green (44, 50.6%), yellow (39, 44.8%) and red (4, 4.6%). The later patients, with theorical contraindication for the procedure, were excluded from analysis. Although less number of clips were needed in green morphology (1.14 vs 1.46; p=0.01), pulmonary vein flow improved more markedly (Table) in these patients. This resulted only in a slightly greater reduction in MR grade at 6 months (−2.5 vs −1.9; p=0.008). No differences were noted in follow up absolute MR grade or changes in ventricular volumes, LVEF or pulmonary artery systolic pressure. Moreover, there was no impact in MACE during the evolution. Conclusion Excluding contraindicated group, no relevant echocardiographic or clinical impact was noted regarding eligibility criteria for percutaneous edge-to-edge mitral repair. Thus, suboptimal patients may equally benefit from this therapy even in moderate-volume centers. Funding Acknowledgement Type of funding sources: None. Table 1. Postprocedural pulmonary vein flow pattern in relation with eligibility criteria

Ischemic Mitral Regurgitation: A Multifaceted Syndrome with Evolving Therapies.

Dysfunction of the left ventricle (LV) with impaired contractility following chronic ischemia or acute myocardial infarction (AMI) is the main cause of ischemic mitral regurgitation (IMR), leading to moderate and moderate-to-severe mitral regurgitation (MR). The site of AMI exerts a specific influence determining different patterns of adverse LV remodeling. In general, inferior-posterior AMI is more frequently associated with regional structural changes than the anterolateral one, which is associated with global adverse LV remodeling, ultimately leading to different phenotypes of IMR. In this narrative review, starting from the aforementioned categorization, we proceed to describe current knowledge regarding surgical approaches in the management of IMR.

Hypertrophic cardiomyopathy with moderate septal thickness and mitral regurgitation: long-term surgical results.

The aim of this study was to assess the long-term outcomes of different surgical strategies in patients with hypertrophic obstructive cardiomyopathy (HOCM) with septal thickness ≤18 mm and systolic anterior motion (SAM)-related moderate-to-severe mitral regurgitation (MR). Seventy-six HOCM patients with septal thickness 17 [16; 18] mm, resting left ventricle outflow tract gradient 60 [41; 85] mmHg and SAM-related MR ≥2+/4+, underwent septal myectomy alone (54%) or mitral valve (MV) surgery ± myectomy (46%). No hospital death and no ventricular septal defect occurred. Patients undergoing MV surgery ± myectomy had longer cardiopulmonary bypass and X-clamp times (77 [60-106] vs 51 [44-62] min, P < 0.001 and 56 [45-77] vs 32 [28-41] min, P < 0.001) and higher incidence of low output syndrome (11% vs 0%, P = 0.04). Follow-up was 98.6% complete, median 8 years [3-11]. There were no statistically significant differences in overall survival (P = 0.069) with survival rates at 9 years of 96 ± 4% in the myectomy alone group and 81 ± 8% in the MV surgery ± myectomy one. At 9 years, cumulative incidence function of cardiac death was 12 ± 6% in the MV surgery ± myectomy group vs 0% in the myectomy one, P = 0.06. Multivariable analysis identified age and previous septal alcoholization as predictors of cardiac death (hazard ratio (HR) = 1.1, 95% confidence interval (CI) 1.0-1.1, P = 0.004 and HR = 2.9, 95% CI 1.0-8.3, P = 0.042). The 9-year cumulative incidence function of recurrence of MR ≥2+, with death as competing risk, was 3 ± 2.8% in the MV surgery ± myectomy group vs 25 ± 6.9% in the myectomy one, P = 0.005. In HOCM patients with moderate septal thickness and SAM-related MR, as the degree of septal hypertrophy decreases, addressing the abnormalities of the MV apparatus may become necessary to provide a durable resolution of left ventricle outflow tract obstruction and SAM-related MR. However, performing myectomy alone, whenever possible, seems to be associated to a better postoperative course and a trend towards lower cardiac mortality at follow-up, despite a higher rate of residual moderate MR.

Increased Monocyte Count is Related to the Development of Atrial Fibrillation in Subjects with Heart Failure

Determining subjects with heart failure (HF), who have a high risk of developing atrial fibrillation (AF), is crucial since it is related to an increase in morbidity and mortality. The importance of an increase in inflammatory response cannot be ignored in developing AF in subjects with HF. This study’s goal was to evaluate the relationship between the development of AF and monocyte count, the main components of the inflammatory response, in subjects with HF. Medical data of 158 subjects in total with sinus rhythm, admitted to the emergency department and hospitalized with systolic HF between January 2009 and February 2014, were analyzed prospectively. All the subjects followed up in terms of the development of AF. The subjects separated into two groups according to their rhythm at the end of the follow-up period. Group 1 included subjects who maintained sinus rhythm, while Group 2 included subjects with AF. Echocardiographic findings and laboratory data were collected. No statistically significant difference was determined between the groups concerning age, sex (p=0.056), hypertension, diabetes mellitus, and smoking status. The two groups differed significantly regarding the presence of moderate-to-severe mitral regurgitation (MR) [32 (28%) vs. 22 (51%), p=0.010] and monocyte count [560 (20-3100) vs. 800 (380-1510) μL, p&lt;0.001]. The multivariate Cox regression model demonstrated that an association of monocyte count (HR=2.397, 95% CI =1.397-4.112, p=0.002) and moderate-to-severe MR (HR= 2.347, 95% CI=1.276-4.316, p=0.006) with the development of AF remained following the adjustment for the variables, which had determined to be statistically significant as a result of the univariate analysis and related to monocyte count. The present study concludes that increased monocyte count in subjects with HF is related to the development of AF. However, further large-scale research required for confirming the findings, as mentioned above.

Increased Monocyte Count is Related to the Development of Atrial Fibrillation in Subjects with Heart Failure

Determining subjects with heart failure (HF), who have a high risk of developing atrial fibrillation (AF), is crucial since it is related to an increase in morbidity and mortality. The importance of an increase in inflammatory response cannot be ignored in developing AF in subjects with HF. This study’s goal was to evaluate the relationship between the development of AF and monocyte count, the main components of the inflammatory response, in subjects with HF. Medical data of 158 subjects in total with sinus rhythm, admitted to the emergency department and hospitalized with systolic HF between January 2009 and February 2014, were analyzed prospectively. All the subjects followed up in terms of the development of AF. The subjects separated into two groups according to their rhythm at the end of the follow-up period. Group 1 included subjects who maintained sinus rhythm, while Group 2 included subjects with AF. Echocardiographic findings and laboratory data were collected. No statistically significant difference was determined between the groups concerning age, sex (p=0.056), hypertension, diabetes mellitus, and smoking status. The two groups differed significantly regarding the presence of moderate-to-severe mitral regurgitation (MR) [32 (28%) vs. 22 (51%), p=0.010] and monocyte count [560 (20-3100) vs. 800 (380-1510) μL, p&lt;0.001]. The multivariate Cox regression model demonstrated that an association of monocyte count (HR=2.397, 95% CI =1.397-4.112, p=0.002) and moderate-to-severe MR (HR= 2.347, 95% CI=1.276-4.316, p=0.006) with the development of AF remained following the adjustment for the variables, which had determined to be statistically significant as a result of the univariate analysis and related to monocyte count. The present study concludes that increased monocyte count in subjects with HF is related to the development of AF. However, further large-scale research required for confirming the findings, as mentioned above.

Prognostic role of sonographic decongestion in patients with acute heart failure with reduced and preserved ejection fraction: a multicentre study

Abstract Aims Our aim was to assess the dynamic changes of pulmonary congestion (PC) through variations of sonographic B-lines, in addition to conventional clinical, biohumoral and echocardiographic findings, to improve prognostic stratification of patients admitted for acute heart failure with reduced and preserved ejection fraction (HFrEF, HFpEF). Methods In this multicenter, prospective, observational study, lung ultrasound was performed in all patients at admission and before discharge by trained investigators, blinded to clinical findings and outcomes. Results We enrolled 208 consecutive patients admitted for acute heart failure (125 HFrEF, 83 HFpEF, mean age 75.9±11.7 years, 36% females, mean ejection fraction 38%). After 180-day follow-up, 38 composite endpoint events occurred (cardiovascular deaths or HF re-hospitalisations). In a multivariate model, B-lines at discharge had independent prognostic value in the overall population together with NT-proBNP, moderate-to-severe mitral regurgitation (MR) and inferior vena cava diameter at admission. When dividing the population in HFrEF and HFpEF, B-lines at discharge was the only independent parameter to predict events in all subgroups. At ROC analysis, a cut-off of B-lines&amp;gt;15 at discharge displayed the highest accuracy in predicting adverse events (AUC=0.80, p&amp;lt;0.0001). The identification of patients unable to halve B-lines during hospitalization (ΔB-lines%), in addition to B-lines &amp;gt;15 at discharge, improved event classification (integrated discrimination improvement=4%, p=0.01; continuous net reclassification improvement=22.8%, p=0.04). Conclusions The presence of residual subclinical sonographic PC at discharge predicts adverse events in the whole spectrum of acute HF patients, independently of conventional biohumoral and echocardiographic parameters. The dynamic evaluation of pulmonary decongestion during hospital stay can further improve patient risk stratification. Funding Acknowledgement Type of funding source: None

Aortic Valve Deformation During Transcatheter Mitral Valve Replacement

A 79-year-old man underwent transcatheter mitral valve replacement (TMVR) with the Tendyne system (Abbott, Santa Clara, California) for moderate-to-severe mitral regurgitation (MR) owing to bileaflet prolapse in the middle-lateral scallop ([Figure 1A][1], [Video 1][2]). Pre-operative computed

Association between mitral regurgitation and clinical outcome after endovascular thrombectomy in stroke patients

ABSTRACT Objective Some hyperacute stroke patients have unfavorable outcomes after endovascular thrombectomy (EVT) despite successful recanalization. We hypothesized that a cardiac parameter, moderate-to-severe mitral regurgitation (MR), might decrease the rate of favorable clinical outcome after EVT in patients with atrial fibrillation (AF). Method From our prospective EVT registry, AF patients who underwent transthoracic echocardiography (TTE) were retrospectively analyzed. Based on the presence of moderate-to-severe MR, patients were assigned to either significant MR or nonsignificant MR group. The severity of MR was determined by the ratio of the color Doppler jet area to the left atrial area in mid-systole. Moderate-to-severe MR was estimated to be at a ratio of >20%. Favorable outcome was defined as having a modified Rankin Scale score of 0–1 at 3 months. Result 127 patients with AF who underwent TTE were included in the study. TTE results found that 25 (20%) patients had significant MR. Patients with significant MR were older (p = 0.051) and had enlarged left (p = 0.015) and right (p = 0.002) atria. Tricuspid and aortic regurgitation (p = 0.007 and 0.043, respectively) were more severe in significant MR group. At 3 months, favorable outcomes were 11% in the significant MR group and 26% in the non-significant MR group (p = 0.031). Multivariate regression analysis reported that moderate-to-severe MR was a negative predictor of favorable outcome (odds ratio = 0.14; 95% confidence interval = 0.02, 0.84; p = 0.031). Conclusions Significant MR might prevent the clinical recovery of AF patients.

Clinical Impact of Valvular Heart Disease in Elderly Patients Admitted for Acute Coronary Syndrome: Insights From the Elderly-ACS 2 Study

BackgroundElderly patients are under-represented in clinical trials and registries, and a gap of evidence exists for clinical decision making in the setting of acute coronary syndromes (ACS). We aimed to assess the prevalence and independent prognostic impact of valvular heart disease (VHD) diagnosed during the index hospitalization on clinical outcomes among elderly patients with ACS. Included VHDs were moderate-to-severe mitral regurgitation (MR), moderate-to-severe aortic stenosis (AS), or both combined. MethodsWe explored the Elderly-ACS 2 dataset, which includes patients older than 74 years of age diagnosed with ACS and managed invasively. The primary endpoint was a composite of all-cause death, myocardial infarction, disabling stroke, and rehospitalization for heart failure at 1 year; the secondary endpoint was death for cardiovascular causes. Patients were stratified into 4 groups: no VHD, moderate-to-severe MR, moderate-to-severe AS, and both moderate-to-severe MR and AS. ResultsOf the 1443 subjects enrolled, 190 (13.2%) had moderate-to-severe MR, 26 (1.8%) had moderate-to-severe AS, and 13 (0.9%) had both moderate-to-severe MR and AS. When compared with those with no VHD, patients with moderate-to-severe MR had hazard ratios (HRs) for the primary endpoint of 2.04 (95% confidence interval [CI], 1.36-3.07], those with moderate-to-severe AS had HRs of 3.10 (95% CI, 1.39-6.93), and those with both moderate-to-severe MR and AS had HRs of 4.00 (95% CI, 1.65-9.73] (all P < 0.01). Patients with moderate-to-severe MR also had increased risks of cardiovascular death (HR 3.17; 95% CI, 1.57-6.42; P < 0.01), whereas in those with moderate-to-severe AS or both moderate-to-severe MR and AS, a nonsignificant increased risk was observed. ConclusionsIn a contemporary cohort of elderly patients admitted for ACS, VHD was found in 1 of 5 subjects and had an independent, consistent impact on prognosis.

P1781Burden of significant valvular heart disease in elderly patients presenting with acute coronary syndromes

Abstract Background Elderly patients with acute coronary syndromes (ACS) represent a group seldom included in clinical trials and in whom robust data regarding mid-term impact of significant concomitant valvular heart disease are lacking. Purpose Our aim was to evaluate the impact of moderate-to-severe mitral regurgitation (MR), moderate-to-severe aortic stenosis (AS), or both conditions combined on a primary composite endpoint of mortality, myocardial infarction, disabling stroke and re-hospitalization for cardiovascular causes or bleeding within one year in a population of ACS patients included in the Elderly ACS 2 trial. Methods In the multicenter Elderly II ACS Study, 1,443 patients aged &gt;74 y undergoing percutaneous coronary intervention (PCI) for ACS, were randomly assigned to receive prasugrel (5 mg) or clopidogrel (75 mg) and were prospectively followed for 1 year. Amongst these, 1,102 patients received full echocardiographic assessment and were included in the post-hoc analysis (Table 1). Results Survival analysis showed that patients presenting with moderate-to-severe MR, AS or both (Figure 1A), had worse outcome in terms of primary endpoint (p&lt;0.001) as compared to no valve disease. A multivariable Cox regression model revealed that the presence of moderate-to-severe MR, AS or both were independent predictors of primary endpoint (HR 1.84; HR 2.8; HR 2.9 and p&lt;0.001; p=0.004; p=0.01, respectively), regardless of age, gender, left ventricular ejection fraction, diabetes mellitus, history of cancer and total number of diseased vessels (Figure 1B). Table 1 Overall No residual valvular heart disease Moderate-to-severe MR Moderate-to-severe AS Both Age (y) 80.68±4.50 80.40±4.42 81.47±4.45 82.92±5.42 83.23±5.42 Male gender 652 (59.2) 538 (61.6) 92 (48.4) 19 (73.1) 3 (23.1) STE-ACS 420 (38.1) 319 (36.5) 91 (47.9) 6 (23.1) 4 (30.8) Diabetes mellitus 203 (18.4) 158 (18.1) 35 (18.4) 5 (19.2) 5 (38.5) LVEF (%) 48.30±9.58 49.26±9.27 44.61±9.45 48.50±11.22 38.31±10.87 History of cancer 32 (2.9) 26 (3.0) 3 (1.6) 2 (7.7) 1 (7.7) Tot number of diseased vessel 2.31±1.05 2.28±1.04 2.49±1.05 2.04±0.87 2.54±1.13 Data are expressed as mean ± SD or count (valid %). Figure 1 Conclusions Moderate-to-severe MR and AS represent significant predictors of 1-year outcome in elderly patients hospitalized for ACS, even when other well-established prognostic factors are taken into account and after revascularization with PCI. Therefore, these patients should be carefully screened for the presence of valvular heart disease at the time of presentation and the need for surgical or percutaneous correction should be assessed accordingly. Acknowledgement/Funding None

Mid-Term Outcome for Anomalous Origin of the Left Coronary Artery From the Pulmonary Artery

This study is a single-centre experience with surgical intervention of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). A retrospective review was performed of patients who underwent ALCAPA repair between November 1991 and October 2017. A total of 138 patients with a median age of 36 months underwent ALCAPA repair. The median follow-up period was 3.5 years. Overall, 114 (82.6%) patients received coronary reimplantation, 21 (15.2%) underwent Takeuchi repair, and three (2.1%) were treated by closure of the ALCAPA plus coronary artery bypass graft. Concomitant mitral repair was performed in 50 patients with moderate-to-severe mitral regurgitation (MR). Three (2.1%) patients died in hospital. Three (2.1%) patients needed extracorporeal membrane oxygenation (ECMO) support. Seven (5.0%) patients needed delayed sternal closure. In patients with decreased preoperative left ventricular ejection fraction (LVEF) (<50%), the LVEF significantly improved from 25% to 33% at discharge (p = 0.001). The percentage of more than moderately significant MR decreased from 36.2% to 5.2% (p = 0.02). There was no late mortality. Two patients needed reoperation because of baffle leaks after Takeuchi repair. Three patients had severe MR. All patients had normal LVEF at last follow-up. The median normalisation time of left ventricular function was 6 months. Short-term and mid-term outcomes of surgical treatment for ALCAPA patients were excellent. The concomitant mitral valve repair did not increase the perioperative risk but had satisfactory mid-term outcomes. Normalisation of left ventricular function is expected within the first 6 months.

Assessment of decreased left ventricular longitudinal deformation in asymptomatic patients with organic mitral regurgitation and preserved ejection fraction using tissue-tracking mitral annular displacement by speckle-tracking echocardiography.

Application of speckle-tracking echocardiography (STE) provides rapid assessment of tissue-tracking mitral annular displacement (TMAD). We investigated the value of TMAD for the assessment of decreased LV longitudinal deformation in asymptomatic patients with severe or moderate-to-severe mitral regurgitation (MR) and preserved LV ejection fraction (LVEF). We retrospectively studied 50 patients with severe or moderate-to-severe organic MR and preserved LVEF (>60%) in whom global longitudinal strain (GLS) was successfully measured by STE. TMAD was quickly assessed in the apical four-chamber view using STE. We calculated the percentage of TMAD to LV length from the midpoint of mitral annulus to the apex at end-diastolic (%TMAD). The study population was divided into two groups: decreased GLS patients (>-20%; Group A) and preserved GLS patients (≤-20%; Group B). We examined whether %TMAD could be used as a diagnostic factor of decreased GLS. %TMAD was significantly lower in Group A than Group B (12.5±0.5 vs 16.8±2.2, P<0.0001). By univariate logistic regression analysis, %TMAD was a diagnostic factor of decreased GLS. By multiple regression analysis, %TMAD remained an independent diagnostic factor of decreased GLS (Odds ratio [OR]=4.21, 95% confidence interval [CI]=1.34-28.94, P<0.0001). A cutoff value of %TMAD <14.6 had a sensitivity of 94% and specificity of 94% for the presence of decreased GLS. Tissue-tracking mitral annular displacement is useful in the assessment of decreased LV longitudinal deformation in asymptomatic patients with severe or moderate-to-severe MR and preserved LVEF.

End-Tidal CO2 Predicts Reduction in Mitral Regurgitation in Patients Undergoing Percutaneous Mitral Valve Edge-to-Edge Repair

Objectives: We evaluated end-tidal CO₂ (etCO₂), which has been proposed to assess acute hemodynamic changes, to guide percutaneous edge-to-edge mitral valve repair (PMVR) with the MitraClip system. Methods: Thirty-nine patients (aged 78 ± 14 years) undergoing PMVR for moderate-to-severe mitral regurgitation (MR) of primary and secondary etiology were included. General anesthesia was maintained with sevoflurane and constant ventilation parameters to ensure stable etCO₂ tension. MR grade was determined semiquantitatively by transesophageal echocardiography by 2 experienced operators blinded to etCO₂ measurements. etCO₂ levels were measured 3, 5, 10, and 15 min after final MitraClip placement. Results: Overall, etCO₂ increased from 32.2 ± 1.7 before to 35.4 ± 3.0, 34.6 ± 2.6, and 34.2 ± 2.4 mm Hg 3, 5, and 10 min after implantation. A significant correlation was noted between the echocardiographic reduction in MR grade and the increase in etCO₂. ANOVA for repeated measures confirmed a significant increase in etCO₂ after clip implantation (corrected F = 20.0; p < 0.001) and revealed a significantly greater increase in etCO₂ in patients with MR reduction ≥2 grades as compared to lesser MR reductions (F = 6.47; p = 0.015). Blood pressure changes did not correlate with the degree of MR reduction. Conclusions: We observed a close correlation between the reduction in MR grade during PMVR and etCO₂, which might evolve as a useful parameter to complement treatment guidance during PMVR.

Impact of interventional edge-to-edge repair on mitral valve geometry

Background/objectivesThe acute and long-term effects of interventional edge-to-edge repair on the mitral valve (MV) geometry are unclear.We sought to assess MV-annular geometry and the association of changes in MV-diameters with functional response one year after MitraClip implantation. MethodsConsecutive patients (n=84; age 81.2±8.3years, logistic EuroSCORE 21.7±17.9%) with symptomatic moderate-to-severe mitral regurgitation (MR) underwent MitraClip-procedure. MV-annular geometry was assessed with 3D TOE before, immediately and one year after clip implantation. Results96.7% of secondary mitral regurgitation (SMR) patients presented with moderate-to-severe MR, 3.3% with severe SMR, respectively. 66.7% of primary MR (PMR) patients had moderate-to-severe MR, and 33.3% severe PMR respectively. When analyzing immediate effects of MitraClipC on mitral geometry, only patients with SMR (n=60, 71.4%) experienced significant reductions of the diastolic MV anterior-posterior diameters (AP: 3.9±0.5cm, 3.5±0.7cm; p<0.001), and annulus-areas (2D: 12.9±3.8cm2, 12.6±3.7cm2; p<0.001; 3D: 13.4±3.8, 13.1±3.2cm2; p<0.001). All measures on MV annular geometry were not significantly altered in patients with PMR (p>0.05).After one year of follow-up, MV annular parameters remained significantly reduced in SMR patients (p<0.05) and remained unchanged in subjects with PMR (p>0.05).Only SMR patients experienced significant increase in 6min walking distances (p=0.004), decrease in pulmonary pressures (p=0.007) and functional NYHA-class (p<0.001); in patients with PMR only NYHA class improved after one year (p<0.001). ConclusionEdge-to-edge repair with the MitraClip-system impacts on MV-geometry in patients with SMR with stable results after 12months. Reduction of MV-annular dimensions was associated with higher rates of persisting MR reduction and better functional status in patients with SMR.

Impact of Septal Reduction on Left Atrial Size and Diastole in Hypertrophic Cardiomyopathy.

Both myectomy and alcohol septal ablation (ASA) can substantially reduce left ventricular (LV) outflow obstruction, relieve symptoms, and improve outcomes in hypertrophic cardiomyopathy (HCM). It is unclear whether septal reduction decreases left atrial (LA) size and improves diastolic function. The aim of this study was to analyze the consequences of septal reduction on LA size and diastolic function in a cohort of patients with HCM. Forty patients (mean age: 50 ± 14, male sex 64%) with HCM who underwent septal reduction (myectomy or alcohol septal ablation) were studied. Retrospective analyses of echocardiograms preprocedure, postprocedure, and at 1 year of follow-up were performed. Thirty-one patients had septal myectomy and 9 ASA. The degree of reduction in rest peak LV outflow tract gradient was significant (57 ± 32 vs. 23 ± 20 mmHg at 1 year, P < 0.001). Maximal interventricular septal thickness decreased from 22 ± 6 mm preprocedure to 19 ± 4 mm postprocedure (P < 0.001); moderate-to-severe mitral regurgitation (MR) was initially present in 34% of the sample and only 2% after the procedure. Average LA volume index (LAVI) decreased from 63 ± 20 to 55 ± 20 mL/m(2) at the 1-year follow-up (P < 0.001). We did not observe a significant improvement in diastolic function at Doppler (E/A 1.2 ± 0.4 vs. 1.1 ± 0.5, P = 0.07; E' 7.6 ± 3.6 vs. 6.9 ± 3.0, P = 0.4) pre- and postprocedure, respectively). At 1 year, only 5% of the patients were severely symptomatic (NYHA III). On multivariate analysis, a significant change in the LVOT gradient during stress (Δ gradient ≥30 mmHg) was the only variable independently associated with LAVI reverse remodeling >10 mL/m(2) [OR = 6.4 (CI 95% 1.12-36.44), P = 0.04]. Septal reduction is effective in the relief of LV obstruction and symptoms in patients with HCM. The hemodynamic changes result in a significant LA reverse remodeling, but not in an improvement of diastolic function in these patients.

Long-Term Outcomes of Mitral Valve Repair in Degenerative Valve Disease: Comparison Between Posterior and Anterior or Bileaflet Mitral Valve Prolapse

Objective: The aim of this study is to compare the clinical and echocardiographic outcome of mitral valve repair secondary todegenerative mitral valve regurgitation in patients with posterior versus anterior or bileaflet mitral valve prolapse.Methods: Between April 1997 and July 2013, 255 patients underwent surgery for moderate to severe degenerative mitral valveregurgitation: 175 had posterior mitral valve prolapse (Group 1) and 80 had anterior or bileaflet mitral valve prolapse (Group2). There were no differences in age or sex between the groups. Clinical follow-up was completed in 95% of the cases witha mean follow-up period of 5.6 ± 3.8 years and 77% completed echocardiographic follow-up with a mean of 4.8 ± 3.7 years.Results: The procedure was successful in 87% of cases (33 intraoperative conversions to mitral valve replacement) (Group1: 98% vs. Group 2: 62.5%; p < 0.01). Overall in-hospital mortality was 2.3% (6/255), and 10-year survival was 92.0 ± 2.1%(Group 1: 94.4% ± 2.2% vs. Group 2: 86.3 ± 5.1%; p = 0.036). At 10-year follow-up, 95.6 ± 1.6% of patients were free fromreoperation (Group 1: 97.1 ± 1.4% vs. Group 2: 89.7 ± 5.0%; p = 0.035), 79.0 ± 4.4% remained free from moderate to severemitral regurgitation (Group 1: 80.8 ± 4.8% vs. Group 2: 71.9 ± 9.6%; p = 0.14) and 91.2% were asymptomatic (92% Group1 vs. 89.3% Group 2; p = 0.5).Conclusions: Patients undergoing mitral valve repair secondary to degenerative posterior mitral valve prolapse had highersurvival and lower incidence or reoperation in the long-term follow-up. There were no differences in freedom from moderateto severe mitral regurgitation between both groups at 10-year follow-up.

How I do it: minimally invasive Cox-Maze IV procedure.

Our patient is a 66-year-old female with a 2-year history of atrial fibrillation (AF) and mitral valve prolapse who presented with dyspnea on exertion. She was found to be in AF upon her admission electrocardiogram. A transthoracic echocardiogram was performed demonstrating moderateto-severe mitral regurgitation (MR) with a left atrial (LA) diameter of 5.1 cm and normal left ventricular (LV) function. After completion of her workup, it was decided that the patient would best be treated by a minimally invasive Cox-Maze IV (CMIV) and concomitant mitral valve procedure given her significant MR and symptoms. This article and accompanying video will discuss how the minimally invasive CMIV procedure is performed. Surgical techniques Preparation In order to perform a mini-thoracotomy mitral valve maze procedure, the patient is positioned with the right chest elevated 45° and the hips flat. Transesophageal echocardiography (TEE) is performed to assess the MR, and examine for a patent foramen ovale or clot in the LA appendage. The aortic valve is also evaluated since significant aortic insufficiency is a contraindication to this approach. The patient is prepped and draped in the usual fashion.